The number of health maintenance organization (HMO) plans submitting
Health Plan Employer Data and Information Set (HEDIS) data to the National
Committee for Quality Assurance and allowing public disclosure for 1997, 1998,
and 1999 are shown in boxes. Arrows depict changes in disclosure status of
plans from 1997-1998 and from 1998-1999. Numbers indicate HMOs that withdrew
from public disclosure of HEDIS scores either through submitting data to the
National Committee for Quality Assurance, but declining public disclosure,
or through a failure to submit data. Also depicted are changes in the number
of plans publicly reporting data due to mergers of existing plans or the addition
of newly participating plans.

Table 1. Characteristics of HMOs Allowing
Public Disclosure of HEDIS Scores in 1997 and 1998*

Mukamel DB, Mushlin AI. Quality of care information makes a difference: an analysis of market
share and price changes after publication of the New York State Cardiac Surgery
Mortality Reports. Med Care.1998;36:945-954.Google Scholar

Context Public disclosure of quality data on health maintenance organizations
(HMOs) might improve public accountability, inform consumer decision making,
and promote quality improvement. But, because disclosure is voluntary, some
HMOs could subvert these objectives by refusing to release unfavorable data.

Objective To determine the association between HMO quality of care and withdrawal
from public disclosure of quality-of-care data the subsequent year.

Design and Setting Retrospective cohort study of administrative and quality-of-care data
on HMOs from the National Committee for Quality Assurance (NCQA) annual Quality
Compass databases for 1997, 1998, and 1999, including Health Plan Employer
Data and Information Set (HEDIS) quality scores.

Main Outcome Measure One-year rates of HMO withdrawal from public disclosure of HEDIS scores
for plans in the highest and lowest tertiles of HEDIS scores, adjusted for
method of data collection and plan model type.

Results Of the 329 HMOs that publicly disclosed HEDIS scores in 1997, 161 plans
(49%) withdrew from public disclosure in 1998. Of the 292 HMOs that disclosed
their scores in 1998 (including 130 newly participating plans), 67 plans (23%)
withdrew from public disclosure in 1999. Plans whose scores ranked in the
lowest-quality tertile were much more likely than plans ranking in the highest-quality
tertile to withdraw from public disclosure in 1998 (odds ratio [OR], 3.6;
95% confidence interval [CI], 2.1-7.0) and 1999 (OR, 5.7; 95% CI, 2.7-17.7).

Conclusion Compared with HMOs receiving higher quality-of-care scores, lower-scoring
plans are more likely to stop disclosing their quality data. Voluntary reporting
of quality data by HMOs is ineffective; selective nondisclosure undermines
both informed consumer decision making and public accountability.

Employers,1 government purchasers of
health insurance,2 individual consumers,3 and lawmakers4,5
are seeking more information on the quality of health care. Recently, the
President's Commission on Consumer Protection and Quality in the Health Care
Industry called for widespread public disclosure of quality data by all health
care provider organizations including health plans.6
Public disclosure is seen as a way to enhance informed consumer decision making,7 promote quality improvement,8-10
and increase health plans' accountability for health care delivery.6,11-14

Public disclosure of data on quality by health maintenance organizations
(HMOs), except those enrolling Medicare patients, is voluntary. In 1998, only
32.5% of all HMOs disclosed their scores on the National Committee for Quality
Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) measures,15 the most widely used set of quality indicators. If
health plans that refuse to disclose quality data provide inferior care, publicly
available data would overstate the average quality of HMO care nationally
and result in a distorted picture of how a given plan that discloses quality
data compares with that average. Selective nondisclosure could also undermine
public accountability and quality improvement efforts by weakening the impetus
to improve quality.

Despite the importance of this issue, no peer-reviewed studies have
examined the relationship of HMO quality to willingness to disclose quality
scores. We linked data for multiple years from the NCQA's annual Quality Compass
databases to determine if withdrawal from public disclosure of HEDIS scores
was related to an HMO's HEDIS performance 1 year earlier.

Methods

Study Sample

The NCQA currently uses HEDIS measures, a standardized set of clinical
quality indicators, as the principal clinical criteria for its HMO accreditation
program. Health plans voluntarily submit these data to the NCQA. The NCQA
lists HEDIS scores of individual HMOs in its annual Quality Compass database,
designed for use by health insurance purchasers and consumers. Until recently,
the NCQA allowed plans to decline public disclosure of their HEDIS scores,
yet remain fully eligible for NCQA accreditation. Plans may also disclose
data privately (eg, to large purchasers) but refuse public disclosure.

To determine which HMOs that disclosed HEDIS scores in 1997 (the "1997
cohort," n = 329) or 1998 (the "1998 cohort," n = 292) withdrew from public
disclosure in the subsequent year, we linked the 199716
(the first year of use of HEDIS version 3.0), 1998,17
and 199918 Quality Compass databases (which
reflect plan characteristics and performance in 1996, 1997, and 1998, respectively).
We used a "link-file" database provided by the NCQA to assist in tracking
plans in the Quality Compass databases from year to year, since name changes
were common. In addition to identifying plans that withdrew from public disclosure,
we identified plans that merged or closed from one year to the next. We also
identified HMOs that newly began public disclosure in 1998 or 1999. Last,
we telephoned each HMO that we identified as having withdrawn from public
disclosure to confirm the plan's identity and whether it had changed its name,
merged with another plan, or closed. For the single plan that had closed,
we obtained the date of closure from its parent company.

Data Collection

The NCQA requires HMOs to follow a detailed guide that defines each
HEDIS measure and specifies standards for data collection. Plans may garner
data from administrative records (administrative method) or supplement the
administrative method with chart reviews (hybrid method).

For each quality indicator, the plan first draws a sample from the target
population (eg, for mammography, women aged 52-69 years continuously enrolled
in the HMO for at least 1 year). The HMO then searches administrative records
(eg, payment or radiology files) to determine if the intervention occurred
within a set time frame (eg, 2 years for a mammogram). If no evidence of the
intervention is found, the HMO may choose to search for exclusions (eg, a
history of bilateral mastectomy). For the hybrid method, when administrative
records fail to give evidence either of the intervention or an exclusion,
the plan reviews sampled patients' charts for such evidence. The HEDIS score
is calculated as the number of patients who received the intervention divided
by the number of eligible patients. The hybrid method, used by most plans
for most measures, usually results in higher quality scores.

We assessed HMO quality using all HEDIS measures listed under the NCQA's
rubric, "effectiveness of care." This rubric encompasses 13 distinct measures
for the 1997 cohort, 4 of which are rates for individual childhood immunizations
(measles-mumps-rubella, hepatitis B, diphtheria-pertussis-tetanus, and oral
polio virus), and one of which is a rate for completion of all of these 4
childhood immunizations. For the 1998 cohort, vaccination for varicella and Haemophilus influenzae type B were added as measures and
are included in the rate for completion of all recommended childhood immunizations
that year. To avoid giving undue weight to childhood immunizations, we analyzed
only the combined immunization rate, yielding 9 HEDIS scores for each plan.
We ranked HMOs by quality in 2 ways. First, we ranked HMOs according to their
score on each of the 9 HEDIS measures separately. Second, we ranked HMOs based
on the average of ranks for all individual HEDIS measures for which the plan
submitted data. For this latter analysis, we included only plans reporting
scores on at least 5 of the 9 HEDIS measures. When more than 1 plan reported
the same score, we assigned these plans the same rank. We then divided the
plans into tertiles on the basis of their quality ranks. All analyses were
performed using SAS.21

Outcomes

Our primary outcome was withdrawal from public disclosure of HEDIS scores
1 year after a previous public disclosure. We defined withdrawal as either
(1) a failure to submit any HEDIS scores to NCQA or (2) submission of HEDIS
scores but refusal to allow public disclosure. Plans that disclosed even a
single HEDIS score or that merged and disclosed pooled HEDIS scores were not
considered to have withdrawn. We excluded from our analysis the single plan
that closed.

Statistical Analysis

For each of the 9 separate HEDIS measures we classified plans by whether
their scores fell in the highest, middle, or lowest tertile of the 329 plans
publicly disclosing data in 1997. We then calculated for each quality tertile
the proportion of plans that withdrew from disclosure 1 year later and used
the χ2 test to compare the proportions withdrawing in the highest
and lowest tertiles. We report 2-tailed P values
for all tests.

We repeated this analysis using the 1998 cohort (the 292 plans disclosing
data in 1998), classifying plans according to their quality ranks in 1998
and comparing withdrawal rates 1 year later among plans in the highest- and
lowest-quality tertiles.

Thus, each analysis examined whether the quality rank in a given year
predicted the likelihood of publicly disclosing quality scores in the subsequent
year.

We also used multiple logistic regression to estimate the adjusted odds
ratio (OR) for withdrawal from public disclosure for HMOs in the lowest vs
highest tertile of average plan rank for all 9 measures combined. We considered
plan characteristics (model type, geographic location, and method of data
collection) as potential covariates. The final multivariate models included
only those variables that showed a significant univariate association (P<.05) with the outcome in both cohort years. In addition,
because collecting data by the hybrid method produces higher HEDIS scores
than the administrative method,22 we controlled
for the method of data collection in all multivariate models.

Because our previous research had shown that investor-owned plans achieve
lower HEDIS scores than not-for-profit plans, we also explored the interrelationships
among ownership status, tertile of average rank on HEDIS scores, and the likelihood
of withdrawal from public disclosure with 2 × 2 contingency tables and χ2 tests of significance for both the 1997 and 1998 cohorts. Specifically,
we compared investor-owned and not-for-profit plans with regard to the percentage
of plans in the lowest tertile of average HEDIS rank and the percentage of
plans that withdrew from public disclosure. Last, we compared plans in the
upper and lower tertiles of average HEDIS rank with regard to the percentage
of plans that withdrew from public disclosure among investor-owned and not-for-profit
plans separately.

Finally, to quantify the clinical significance of differences in quality
between the highest- and lowest-quality plans, we calculated the mean (SD)
rates for each indicator for the highest- and lowest-quality tertile.

Results

Characteristics of the Health Plans

The majority of HMOs in both the 1997 and 1998 cohorts were investor-owned
and were independent practice associations or mixed model type plans (Table 1). Plans in both cohorts were most
commonly located in the South Atlantic, Mid Atlantic, and East North Central
regions.

HMO Withdrawal From Public Disclosure of HEDIS Scores

A total of 329 HMOs allowed public disclosure of their HEDIS scores
in 1997 (Figure 1). Of these plans,
161 (49%) withdrew from public disclosure the following year. In 1998, 292
plans allowed public disclosure of their HEDIS scores. This cohort consisted
of 162 plans (after mergers) that allowed public disclosure in 1997, plus
130 newly participating plans. Of these 292 plans, 67 (23%) withdrew from
public disclosure in 1999. For both the 1997 and 1998 cohorts, just over half
of all plans that withdrew from public disclosure continued to submit HEDIS
scores to NCQA (Figure 1).

HMO Quality Rank and Withdrawal From Public Disclosure of HEDIS Scores

HEDIS scores among HMOs that allowed public release of their quality
data varied widely in both 1997 and 1998 (Table 2). Absolute differences in mean HEDIS scores of plans in
the lowest and highest tertiles ranged from 15.6 to 42.3 percentage points
in the 1997 cohort and from 14.6 to 37.5 percentage points in the 1998 cohort.
For example, the mean immunization completion rate for 13-year-olds in the
1997 cohort was 74.7% for plans in the highest-quality tertile, but only 32.4%
for plans in the lowest-quality tertile.

Health maintenance organizations in the lowest tertile were significantly
more likely to withdraw from public disclosure than plans in the highest tertile
for 7 of the 9 measures in the 1997 cohort and for 6 of 9 measures in the
1998 cohort (Table 3). Plans in
the lowest tertile were 1.6 to 2.7 times more likely to withdraw from public
disclosure than plans in the highest tertile in the 1997 cohort and 2.2 to
7.0 times more likely to withdraw in the 1998 cohort. For 7 of the 9 indicators
in the 1997 cohort, more than half of plans in the lowest-quality tertile
withdrew from public disclosure of HEDIS scores the subsequent year. Withdrawal
rates for the 1998 cohort were somewhat lower; nonetheless, for 8 of 9 indicators,
at least 25% of plans in the lowest-quality tertile withdrew the subsequent
year.

Health maintenance organizations in the lowest tertile of overall quality
(average rank for all 9 HEDIS measures) were more likely to withdraw from
public disclosure than plans in the highest tertile in both the 1997 (OR,
3.6; 95% confidence interval [CI], 2.1-7.0) and 1998 (OR, 5.7; 95% CI, 2.7-17.7)
cohorts after adjustment for the method of data collection and plan model
type (the only plan characteristic consistently correlated with plan withdrawal
in univariate analyses).

In our analyses according to plan ownership status, investor-owned plans
were more likely than not-for-profit plans to be in the lowest-quality tertile
in both the 1997 (RR = 3.4; 95% CI, 1.9-5.8) and 1998 (RR = 1.9; 95% CI, 1.3-2.7)
cohorts and to withdraw from public disclosure in both the 1997 (RR = 5.7;
95% CI, 2.6-12.2) and 1998 (RR = 1.3; 95% CI, 0.7-2.5) cohorts, although this
difference was not statistically significant for the latter cohort. It appears,
however, that poor quality rather than profit status per se was the primary
determinant of withdrawal from public disclosure. The poorest-quality plans
were more likely to withdraw from disclosure than the best-quality plans among
both investor-owned plans (RR = 1.5; 95% CI, 1.1-2.1), and not-for-profit
plans (RR = 2.2; 95% CI, 0.5-10.4) in the 1997 cohort. Similar results were
obtained in the 1998 cohort for both investor-owned (RR = 2.7; 95% CI, 1.1-6.6)
and not-for-profit plans (RR = 20.0; 95% CI, 2.8-149.8).

Comment

While the total number of HMOs that publicly disclosed HEDIS quality
scores changed little each year from 1997 to 1999, the composition of this
group changed substantially. Forty-eight percent of plans in the 1997 cohort
and 23% of plans in the 1998 cohort withdrew from public disclosure 1 year
later. Quality scores varied substantially among HMOs, and lower-scoring plans
were much more likely to withdraw.

No previous peer-reviewed studies have examined the relationship between
HMO quality scores and withdrawal from participation in public disclosure
of scores in the HEDIS program. Previous yearly NCQA reports have documented
that nondisclosing plans score poorly. However, our longitudinal analyses
provide a quite different view than these reports based on cross-sectional
data. Our approach encompasses plans that drop out of the HEDIS program entirely,
in addition to those that refuse disclosure. For example, a 1998 NCQA report
that provided data on nondisclosing plans included only 88 of the 161 (nondisclosing
and drop-out) plans we analyzed.

We also delineate, for the first time, the shifting cohort of HEDIS
participants and disclosers. Many plans are disclosers one year and nondisclosers
the next (or vice versa). Hence the manipulation of the HEDIS monitoring system
is more pervasive than is apparent from the NCQA's cross-sectional comparisons.
The differences in analytic approaches also give rise to quite different interpretations.
The NCQA suggests that the better cross-sectional performance of disclosing
plans is evidence that their quality monitoring system is working. In contrast,
our longitudinal data imply that gaming of the system is so extensive as to
potentially undermine the quality monitoring process.

Why do HMO executives at lower-scoring plans choose to withdraw from
reporting of HEDIS scores? They might believe that their plan's low HEDIS
scores result from inadequate data collection methods that could understate
true quality. Perhaps some suspect that their plan will suffer from biased
comparisons since not all plans' data were audited, especially in the earlier
years of the HEDIS program. They may become aware of such issues only after
disclosing HEDIS scores at least once. Some executives may regard the costs
of data collection as too high,23-25
which could explain why some higher-scoring plans withdrew from HEDIS participation.
But costs cannot explain most withdrawals; about half of the plans withdrawing
from public disclosure still collected and submitted HEDIS scores (Figure 1).

The most likely explanation for our findings is that many plans withdraw
because they fear (or know) that they will score low again. Low scores might
place such plans at a marketing disadvantage, especially if nondisclosure
carries little stigma. Regardless of the explanation, however, our results
imply that voluntary disclosure of quality data, the primary national mechanism
for HMO quality oversight, is failing to meet its stated goals of informing
consumer decision making, providing incentives to improve quality and increasing
public accountability.

The NCQA's HEDIS program represents the most comprehensive and influential
quality assessment tool26 for HMOs (and any
health care sector). HEDIS measures are standardized and subject to external
audit to verify the data collection and calculation process.22
Yet, the selective withdrawal by lower-scoring plans means that enrollees,
purchasers, and the public often cannot monitor a plan's quality over time.
Furthermore, it implies that the average quality of HMO care in the United
States is unknowable. Average published HEDIS scores could improve even if
the actual average quality were stable or even deteriorating. Hence, HEDIS
scores cannot be used as an accurate barometer of HMOs' attainment of specific
health goals for the nation.11,27,28

The variation in HEDIS scores that we observed between the highest-
and lowest-scoring plans has substantial clinical relevance. For example,
receiving a β-blocker after a myocardial infarction reduces the risk
of cardiovascular death and nonfatal reinfarction by 22% and 27%, respectively.29,30 Yet in 1998, a patient surviving
a myocardial infarction was only half as likely to receive this medication
if enrolled in a health plan in the lowest compared with the highest tertile
of quality.

Voluntary disclosure allows HMOs to use the HEDIS program as a marketing
tool, sacrificing its value as a quality assessment and improvement tool.
When scores are high, plans can disclose them and take advantage of consequent
marketing benefits. When scores are low, plans can withdraw from public disclosure.
Indeed, until recently, HMOs that refuse to publicly disclose their quality
scores were fully eligible for NCQA accreditation; only 4% of HMO applications
for accreditation were rejected in 1998.31

Investor-owned plans were somewhat more likely to withdraw from public
reporting. However, poor quality was associated with withdrawal from public
disclosure among both investor-owned and not-for-profit plans. Apparently,
the increasingly competitive health care marketplace drives health plans (irrespective
of ownership status) to control data release to maximize competitive advantage.

Lack of disclosure is not the only challenge to the HMO quality oversight
process. Patients appear to have difficulty understanding quality data32,33 and use it infrequently when selecting
a health plan.34,35 Many employers
offer only 1 health insurance option,36 foreclosing
patient choice. Even large employers make only limited use of quality data,1,8 instead, selecting health plans primarily
on the basis of cost.1,37 Indeed,
in the current health care market, evidence that public disclosure of quality
data improves quality is equivocal.9,10,38,39
Therefore, improving accountability and encouraging quality improvement would
require, at the very least, that quality data be presented in a patient-friendly
format, that patients be offered a choice of health plans, and that both patients
and large purchasers make purchasing decisions based on quality rather than
price. Without publicly available data on quality, however, achieving these
goals would accomplish little.

Our findings should also be viewed in the context of the broader debate
on public disclosure of quality data by all types of health care provider
organizations. Like HMOs, physicians and hospitals have opposed mandatory
disclosure of performance data. Improvement of quality and accountability
may ultimately depend on forthright disclosure of quality data at all levels
of the health care system.

Our study has several limitations. First, since data on nondisclosing
plans were, by definition, unavailable to us, we used a plan's performance
1 year earlier as a proxy for current performance. Plans know their current
HEDIS scores before having to decide whether or not to disclose them. Thus,
it seems likely that low-scoring plans that improved would choose to continue
disclosing, while those that did not would be more likely to withdraw from
disclosure. Hence, our study may underestimate the relationship between low
scores and withdrawal from disclosure. Second, we cannot exclude the possibility
that unmeasured plan characteristics such as geographic dispersal of medical
provider sites or differences in data systems could systematically influence
our results. Third, although our data show that lower-scoring plans are more
likely to withdraw from disclosure, we have no direct data on HMO executives'
reasoning regarding this decision. Last, only HMOs are currently eligible
to submit HEDIS scores and receive NCQA accreditation. Whether the selective
reporting of quality data we observed would apply to fee-for-service insurance
or other facets of the health care system is unknown.

Few industries whose impact on health rivals HMOs' are as free of public
oversight. Airlines and car manufacturers are required to disclose standardized
data on the safety of their products. Our findings suggest that voluntary
quality reporting by HMOs will not create the preconditions for effective
quality oversight. Reporting and public disclosure of HEDIS and other meaningful
quality data by HMOs should be mandatory.

Mukamel DB, Mushlin AI. Quality of care information makes a difference: an analysis of market
share and price changes after publication of the New York State Cardiac Surgery
Mortality Reports. Med Care.1998;36:945-954.Google Scholar